Broccoli Before Bedtime

 

Leg pain and leg discomfort are very common complaints. These symptoms could be due to serious medical problems or may be due to more benign disorders. If there is leg cramping, deep pain, aching in the calf muscles while walking and relieved by rest the likely diagnosis is peripheral artery disease, a lack of blood flow to the legs. This is a serious condition that should be evaluated by your doctor. When leg symptoms occur at rest, usually at night, two common processes are possible; restless leg syndrome and nocturnal leg cramps. These two disorders are often confused, but they are different entities with different treatments. 

 

Restless leg syndrome is an uncomfortable sensation in the legs with an urge to move the legs. It most often occurs at night, but can occur while sitting in a car or plane. It does not cause pain, it lasts for a few minutes and is relieved with movement. The sensation is described as a creeping, crawling, pulling or throbbing in the legs. It is quite common, occurring in about 7% of people. There is no known cause for restless leg syndrome, but it is associated with an imbalance of a brain chemical called dopamine. It is associated with iron deficiency anemia (low blood count), neuropathy, kidney disease, Parkinson’s disease and pregnancy (affecting 3% to 30% of pregnant women). The treatment depends on the underlying cause. If there is anemia, treatment with oral or intravenous iron is beneficial. However, the vast majority of restless leg syndrome cases are idiopathic, or without known cause. For these patients, nonpharmacologic therapy can include good sleep habits, hot soaks or massage for the legs, and avoiding caffeine at bedtime. Exercise can help. Thirty minutes of aerobic exercise three times per week can improve symptoms, but avoid exercise within a few hours of bedtime. Medications such as gabapentin can relieve symptoms. The use of medications has to be tempered by the risk of side effects; the medication cannot cause significant problems since restless leg syndrome is basically a benign condition. This is the case with ropinirole (Requip). Ropinirole increases the levels of dopamine in the brain and helps symptoms when used for a short period of time (a few weeks). If used long term, symptoms of restless leg paradoxically worsen. In fact, in September 2024, the American Academy of Sleep Medicine recommended against using ropinirole for restless leg syndrome.

 

Nocturnal leg cramps are painful contractions of the leg muscles that occur at night. The cramps are relieved by stretching the muscle. The leg cramps (or charley horses) are common, with up to 60% of people reporting symptoms. In 20% of patients, the cramps are severe enough to cause significant insomnia. The cause of nocturnal leg cramps is not known, like restless leg syndrome an idiopathic process. Leg cramps are not associated with dehydration or low blood levels of potassium or sodium. Nocturnal leg cramps can be caused by a myriad of medications. It can also be associated with peripheral artery disease, heart artery disease, neuromuscular diseases (neuropathy, Parkinson’s disease, multiple sclerosis) and pregnancy. The acute treatment of leg cramps includes stretching and massage of the affected muscle. Mild exercise on a stationary bike or treadmill before bed can help decrease cramping. Multiple medications and supplements have been tried to relieve the symptoms of nocturnal leg cramps. However, like restless leg syndrome, the side effects of the treatments cannot be severe as the disease process itself is not severe. Quinine is a medication that has been shown to reduce the intensity of the cramps and reduce days with cramps; it reduces the number and severity of the cramps. Unfortunately, quinine has serious side effects including low platelets and heart arrythmias. In 2006, the FDA advised against using quinine for nocturnal leg cramps. Magnesium supplements have been used to prevent cramps. Unfortunately, numerous studies have failed to show any benefit. One promising avenue may be vitamin K supplementation. A recent study of 199 patients over the age of 65 showed that a vitamin K tablet decreased the frequency of leg cramps compared to placebo. In general, there are no adverse reactions with vitamin K supplementation. The only contraindication to vitamin K is in patients who are on warfarin, a blood thinner. Vitamin K is used to reverse the effect of warfarin. Vitamin K is found in green leafy vegetables such as kale, spinach, cabbage, lettuce, Brussels sprouts, cauliflower and broccoli. We don’t know whether the same reduction in leg cramping will occur with increasing the intake of vitamin K laden foods; theoretically it should. How would that work? One cup of broccoli contains 164 micrograms of vitamin K, while the supplement used in the trial had 180 micrograms. So, potentially one cup of broccoli at bedtime each night might chase those cramps away. 

Floss For Your Life

 

You know that you are supposed to brush your teeth twice per day and floss regularly to prevent significant dental problems. However, did you know that keeping those pearly whites in tip top shape also helps with overall health, especially heart health? How are your teeth and your heart related? How can better dental health lead to better cardiac health?

Periodontal disease is extremely common and has well know associations with various forms of heart disease. Periodontal disease is a process that affects the supporting structure of the teeth, the gums, the surrounding tissue and the bones supporting the teeth. Periodontal disease is caused by plaque or bacteria on the teeth. This leads to inflammation causing local damage. The bacteria can also enter the bloodstream and lodge in arteries, including the heart arteries. There are two types of periodontal disease: gingivitis and periodontitis. Gingivitis is the milder form of the disease and involves only inflammation of the gums. Periodontitis is a more serious process and a chronic inflammatory disease that affects the teeth, the gums and the bones. Symptoms of periodontal disease include red, swollen, painful or bleeding gums, loose teeth, loss of teeth, and pockets of infection between the teeth and the gums. It is reported that periodontal disease affects more than 1 billion people and is considered the sixth most common disease worldwide.

Many studies have tied periodontal disease to systemic inflammation. Inflammation can be good and it can be bad. Inflammation can fight an injury to the body and help promote healing once the injury has been cured. However, unchecked and ongoing inflammation can also cause long term tissue damage. The bacterial infection in periodontal disease provides a textbook example. Bacteria that are present in dental plaque are also found in the blood stream. The bacteria enter the body through small perforations in the dental tissue and can also be released by tooth brushing. Once in the blood, the bacteria lodge in various arteries, including the heart arteries. Once there, they initiate an inflammatory reaction which leads to damage of the arterial wall and ultimately plaque and blockage in the heart artery. In addition, the dental bacteria increase low density lipoprotein (LDL cholesterol) which then promotes further plaque and blockage in the heart arteries. Studies have shown increased levels of C reactive protein (a marker of inflammation in the blood) associated with periodontal disease.  Treatment of periodontal bacteria with antibiotics decrease bacteria in dental plaque, lower levels of C reactive protein and reduce LDL cholesterol. 

Many, many studies in thousands of patients and in populations from around the world have linked periodontal disease to heart artery disease, heart attack, stroke and cardiac death. Two large studies tied periodontitis (the severe form of periodontal disease) to heart attack. One study reported a 16% increased risk for heart attack with periodontitis and the other had a 28% increased risk. A more recent study (October 2024) found a 9% increase in heart artery disease in all patients with periodontal disease (gingivitis and periodontitis). Another recent study was the first to show that periodontal disease was associated with congestive heart failure (CHF). 

Last month (February 2025), an additional association was made between periodontal disease and atrial fibrillation (Afib) and stroke. The study followed 6200 people, average age 62, for 25 years. Patients who flossed their teeth at least once per week had a 22% lower risk for stroke and a 12% lower risk for Afib. Flossing more led to even further reductions in risk. The benefit of flossing was on top of tooth brushing and regular dental appointments. This may be because flossing cleans the gums better than tooth brushing, removing food and plaque from in between teeth. 

To treat periodontal disease, dentists will prescribe antibiotics. Antibiotics have been shown to kill the bacteria found in dental plaque and reduce inflammatory markers. To treat severe cases, oral surgeons will do surgery.  To prevent periodontal disease and subsequent heart artery blockage and heart attack, stop smoking (smoking causes both periodontal disease and heart disease), brush your teeth twice per day and go for regular dental checkups. To prevent Afib and stroke, floss for your life.

Hearts on Fire

 

The wild fires that have engulfed California are now considered one of the worst natural disasters in US history. Homes have been lost, communities have been destroyed and 40,000 acres have burned, fueled by Santa Ana winds and a prolonged drought. Across the globe, wild fires have become more frequent. In the US, there are more than 70,000 fires per year and the acreage burned has more than doubled over the past 30 years. In addition to property damage, the particulate matter in wild fire smoke is a huge health concern. Cardiac and respiratory deaths have increased over the past twenty years due to wild fires. How do wild fires and the smoke they produce affect heart health?

 

It is well established that air pollution is a major factor in global health. Air pollution causes millions of premature deaths every year, especially in the very young (children < 6 years old), the elderly (over age 65) and in vulnerable groups (those with pre-existing lung or heart disease). Air pollution has been linked to almost every major cardiac disease process including heart attack, heart failure, arrhythmias, hypertension, stroke and cardiovascular death. Polluted air contains particulate matter, fine particles that are suspended in the air. Particulate matter is produced by burning fossil fuels (for example car exhaust), smoke from manufacturing plants, and agricultural activities (such as burning crop residues). These particles are inhaled into the lungs and enter the blood stream. Once particulate matter has entered the body it can trigger various adverse reactions such as inflammation, oxidative stress, stiffening of the wall of the arteries, loss of function in the blood vessels, and increased risk for blood clotting.  

 

Wildfires produce smoke that have similar effects on the body as air pollution. The smoke contains particulate matter, gases (carbon monoxide, nitrous oxide), heavy metals (lead, mercury), and toxic carcinogens (similar to cigarette smoke- benzene, benzopyrene). Wildfire smoke is especially harmful to human health due the fact that smoke can travel thousands of miles and the particulate matter is very dense (wildfire events can increase particulate matter in the air to levels that equal the most polluted cities). Wildfire smoke can impact health in many different ways. It affects respiratory health by worsening lung function, increasing asthma episodes and increasing the risk for lung infections. Particulate matter is also known to affect the kidneys, the gastrointestinal system and can lead to diabetes. Wildfire smoke is associated with high blood pressure, episodes of chest pain, cardiac arrest and worsening heart failure. Exposure to smoke increases hospital admissions for cardiac events. Even short-term exposure to wildfire smoke can result in harm as this type of smoke is more toxic than the particulate matter found in urban air pollution.  It doesn’t take a full wildfire to produce the risks. Even the particulate matter from wood smoke (such as fire pits or camp fires) can trigger these adverse reactions. 

 

Wildfires are not just something that occur 3,000 miles away on the west coast but have happened in our own backyard as well. The 2023 wildfire season in Canada was among the worst in its history. In June 2023, the wildfire smoke traveled more than 2000 miles and affected the Eastern US.  The smoke was gathered and analyzed on the Piscataway campus of Rutgers University. Researchers found that the smoke had very large concentrations of fine particulate matter as well as high amounts of cancer-causing organic compounds. On June 7 2023, the air quality in New York City was the worst on record in 50 years. In addition, on that day, the level of particulate matter was 10 times higher than the national air quality standard. How did that affect health? Asthma related emergency room (ER) visits increased by 82% on June 7 in New York State and by 63% in New Jersey. The New York area was not the only one involved. In Baltimore, the level of particulate matter was 9 times higher on June 7 than any other day in 2023. This resulted in increased visits to ERs and urgent care facilities for heart and lung related problems.

 

What can you do to protect yourself when the next wave of wildfire smoke descends on New Jersey? The best recommendations include staying indoors, with air conditioning or an air purifier. Don’t do any strenuous activity outside (for example exercising, mowing the lawn, gardening). If you have to go out, wear a face mask, preferably an N95 mask. Let’s hope for a fire free 2025.

 

How To Arrest Sudden Cardiac Death

 

Sudden cardiac death (or sudden cardiac arrest) is a common, deadly problem and is often the first manifestation of heart disease. It is an abnormal heart rhythm most often caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart).  When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death.  Sudden cardiac arrest affects 350,00 people in the US each year. Less than 20% of sudden cardiac arrest victims have their rhythm restored to normal and only 10% survive to leave the hospital, which means the death rate is 90%.

 

The cause of sudden cardiac arrest depends on the age of the victim and the type of underlying heart disease.  In patients over the age of 35, the overwhelming cause of sudden cardiac arrest is a heart attack. A heart attack occurs when a plaque or blockage in a heart artery breaks open and a blood clot is formed stopping the blood flow to the heart muscle. It is important to realize that a heart attack and sudden cardiac arrest are not the same thing. A heart attack is one of the causes of sudden cardiac arrest and primarily a plumbing problem (the artery and the blood flow) while sudden cardiac arrest is an electrical problem (an abnormal rhythm). In those under age 35 sudden cardiac arrest is usually caused by a congenital heart problem. The person is born with an abnormal heart muscle, or an abnormal electrical system, or an abnormal origin of one the heart arteries. 

 

The strategies to prevent sudden cardiac arrest from becoming sudden cardiac death include prompt treatment and primary prevention. Prompt treatment involves recognizing that someone is in cardiac arrest, initiating cardiopulmonary resuscitation (CPR) and performing defibrillation as soon as possible. The American Heart Association recommends hands only CPR (chest compression only, no mouth-to-mouth breathing). The initiation of prompt CPR has been shown to save lives. Definitive treatment of sudden cardiac arrest is defibrillation, an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED), a small portable device that is brought to the victim’s side. The sooner the patient is shocked, the greater the chance of surviving. Fifty percent of victims of sudden cardiac arrest survive if shocked within two to three minutes, but only ten percent will live if the shock is more than ten minutes from the time of collapse.  Every minute spent waiting for an AED decreases the odds of survival by 7-10%. Having an AED as close as possible to potential victims is lifesaving.  

 

The biggest barriers to successful resuscitation are getting an AED to the victim as soon as possible and having bystanders deploy the device. Fortunately, AEDs seem to be everywhere. About 500,000 to 1 million were sold in the US last year and there are about 3.2 million AEDs in public settings. AEDs are placed in areas where there are large public gatherings (such as airports, schools, stadiums, sports complexes). AEDs have been successfully deployed by police, firemen, sports trainers, and bystanders. In large public spaces, how close together should AEDs be placed?  The American Heart Association recommends an AED within a 3-to-5 minute round trip walk from anywhere in a public place. This translates to each AED covering about 100 yards in each direction. Aside from large public spaces, where should AEDs placed so bystanders can find and use them? One study from Toronto showed coffee shops and bank ATMs to be the best for coverage. A study from England felt that AEDs near mailboxes was best. A study from Taiwan concluded that bus stops, convenience stores and pharmacies were optimal. All studies emphasized areas where the public would be familiar with the AED location, potentially enhancing the use of AEDs by bystanders. 

 

Unfortunately, only 15% of sudden cardiac arrests take place in a public area. The vast majority (85%) of events take place in a private home. In the private setting, it is estimated that only 6% of sudden cardiac arrest victims might have an AED close enough for use. What is the optimal density of AEDs and how can they be brought to victims in residential areas? Multiple studies have concluded that the optimal density of AEDs is between 5 and 41 AEDs per square mile. Unfortunately, in a country as large as the United States, this density will be difficult to achieve nationwide. To increase AED coverage, especially in remote areas, multiple studies have advocated using drone delivery of AEDs to cardiac arrest patients. One study showed that drone delivery of an AED was 3 minutes faster and beat ambulance arrival in 67% of cases. In a situation where time is critical, drones may make a difference.

 

Unfortunately, even when an AED is available, it may not be used. One recent study reported that even if an AED was one minute walk away from a victim, bystanders only used the device 16% of the time. Fortunately, on December 10 2024, Congress passed the HEARTS Act expanding access to AEDs and increasing training for CPR and AED use. 

 

Primary prevention aims to identify people who may at risk for sudden cardiac arrest before an event occurs. This is especially important since cardiac arrest is often the first manifestation of heart disease in a person. For those over 35 years old, there are no specific recommendations for screening.  General measures to reduce the risk for heart attack are emphasized including following a heart healthy lifestyle (staying active, watching a good diet, not smoking, keeping weight under control, treating high blood pressure and/or high cholesterol). Routine stress testing doesn’t reduce the risk for cardiac mortality, but doing a stress test before starting an exercise program is prudent, especially if there are one or more cardiac risk factors. One way to reduce the risk for sudden cardiac arrest is exercise. One recent study showed that vigorous physical activity of 20 minutes per week reduced the risk for cardiac arrest. Moderate exercise of 360 minutes per week (51 minutes per day) also lowered cardiac arrest risk. 

 

For athletes who are under the age 35, screening is performed. Although cardiac arrest is rare in athletes (1 in 63,00 college athletes have cardiac arrest each year) certain populations are at higher risk. Men have 2 to 10 times the risk as women. Black athletes have 5 times the risk compared to white athletes. Athletes in certain sports (basketball, soccer, cycling and football) are at higher risk. Screening involves a questionnaire asking about symptoms and family history. An electrocardiogram (EKG) is performed on all athletes and a cardiac ultrasound (echocardiogram) is done on those with high risk (for example someone with an abnormal EKG). Many professional athletes (especially football, basketball and soccer players) are screened before a contract is signed.  In addition, Division 1 college athletes are screened. Although screening is controversial, it has been shown that screening prevents sudden cardiac arrest in multiple populations. A recent study reported that sudden cardiac arrest has been steadily declining in college athletes over the past 20 years. 

 

What can the average person do to reduce the risk for sudden cardiac arrest personally and in the community? On a personal level, follow a good heart healthy lifestyle and keep up with the recommended amount of exercise. From the community standpoint, take a CPR class at a local hospital. Most classes teach basic CPR and the proper use of an AED. In addition, take notice of the location of AEDs during your daily activities. You never know when you might use one. 

 

 

How to Fix a Christmas Carol Earworm and Other Healthy Holiday Tips

Everyone has had this experience. You are minding your own business and, all of a sudden, a tune pops into your head. It could be a favorite song or a song you heard on your favorite streaming service. It could be a jingle for a product or a medication. At this time of year, it could be a Christmas carol. The refrain or the catchy lyrics play over and over in your head and you can’t seem to get rid of it. What is this phenomenon?  Why do certain jingles jangle around in the mind?  Why are holiday songs so prone to being stuck in the brain?

 

The experience of having music looping in one’s head is commonly known as an earworm. Other names for the phenomenon are stuck song syndrome, sticky music and musical imagery repetition. The medical term is involuntary musical imagery.  The term earworm was coined in 1979 by a psychiatrist and is derived from the German word ohrwurm, which means musical itch. Earworms mostly appear spontaneously. They can occur when the mind is wandering or daydreaming. They can be associated with exposure to a song, either immediately or, more commonly, many hours later.  An earworm can be triggered by a song that evokes a strong memory or specific situation.  Women are more prone to earworms than men as are those who are musically inclined. The typical loop of music lasts from 20 to 30 seconds and plays back over and over for about 10 to 30 minutes, although rare cases can last for hours. Songs that have faster tempos or long, sustained notes are more likely to stick in the head. 

 

The first known ad jingle was aired in 1926 on a radio station in Minneapolis. The ad was for the cereal Wheaties and each time the jingle was played, it was sung live in the radio studio. The ad (and the jingle) was successful, increasing sales of Wheaties by 60%, possibly by triggering midwestern earworms. The study of earworms far preceded the Wheaties jingle. Earworms have been studied since 1885. However, modern media (radio, television, music streaming) have bombarded us with songs and jingles and have made earworms extremely common. A study of 12,000 people from Finland found that 89% of people experienced an earworm at least once per week. About 20% of participants had an earworm multiple times a day. They also found that earworms decreased with advancing age. The incidence of earworms was confirmed in a study of 240 college students published in 2020. In the study, 97% of participants had an earworm within the past month. 

 

Holiday songs are fertile ground for earworms for multiple reasons. First, there is opportunity. The songs are everywhere at this time of year (on radio, on television, in stores) and played constantly. Holiday songs also evoke strong memories, which in turn can unearth an earworm. The structure of the songs themselves are conducive to promoting earworms. Holiday music by design is simple and singable. The simple structure is easy for the brain to memorize thus laying down tracks in our minds for future playback. Lastly, many holiday songs have a common chordal structure. These chords are pleasant and festive evoking good memories; ripe territory for an earworm.

 

Is that holiday song rattling around the ear canal dangerous? Most of the time, earworms are harmless. In fact, they are part of a healthy brain and help us lay down memories. On the other hand, patients with obsessive compulsive disorder can have earworms under stress and earworms that last for hours and hours can be a sign of depression. If an earworm is accompanied by other symptoms, such as blacking out, confusion, loss of vision or a seizure, then a medical evaluation is indicated. 

 

So, earworms are not usually harmful but they can be annoying. How can we scratch this musical itch?  There are several proven ways to rid oneself of an earworm. One way is to walk at either a faster or slower pace than the tempo of the song. Another way is distraction. Read a book, watch a movie or engage in a task that requires concentration. This will redirect the brain. Speaking of redirecting, try changing your environment; go into a different room or take a walk outside. Another obvious approach is listening to a different song. One less obvious way to get rid of an earworm is to chew gum!

 

Aside from squishing holiday song earworms, what other recommendations can be made for a healthy holiday? Here are eight essential ingredients, loosely modeled after the American Heart Association Life’s Essential Eight:

1.     Diet: try to stick to a heart healthy Mediterranean diet

2.     Diet: try to limit sugary treats and snacks

3.     Diet: when possible while cooking, substitute olive oil for butter 

4.     Exercise: try to maintain your regular exercise program during the holidays

5.     Alcohol: try to limit alcohol. If you are drinking, limit to just one per night

6.     Socialize: with family and friends, as much as possible

7.     Sleep: try to maintain your regular sleep pattern and duration

8.     Weight: try not to gain too much weight at the holidays!

 

Let’s have a safe, healthy and earworm free holiday season!

 

The Presidential Coronary Calcium Score and the Power of Zero

 

“Maybe I’ll win

Saved by zero”

The Fixx, 1983

 

Since the 1990’s, the U.S. Presidents and the Presidential candidates have undergone coronary calcium scores. What can we learn from their results? Let’s look at two examples. Let’s call them the Clintons. Hillary Clinton reportedly had a coronary calcium score of 0. As far as we know, she has not had any heart disease. Bill Clinton’s coronary calcium score was over 1000. He subsequently required open heart bypass surgery. Can you guess the coronary calcium scores of Presidents George Bush, Barack Obama and Donald Trump? What is the coronary calcium score and can you be “saved by zero”?

 

To understand coronary calcium, we must understand the process of atherosclerosis in the heart arteries. In susceptible individuals, plaque formation starts at an early age, the 20’s and 30’s. The initial plaque in the heart arteries is made of cholesterol, what is called “soft” plaque or “fatty” plaque. If we did a CT scan at this stage, no calcium would be detected. Over time, plaque progression continues and by the age of 50 to 60, calcium is deposited in the plaque. The plaque is now considered “hard” plaque. At this stage, a CT scan would detect calcium in the artery. Coronary calcium therefore detects the presence of plaque in the heart arteries. It does not tell us if the plaque is limited to the artery wall or if the plaque is causing significant blockage to the blood flow (obstruction can be determined with a stress test or a heart catheterization).  

 

What is the coronary calcium score and how is it used? Coronary calcium score is obtained with a CT scan. There is no fasting, no preparation, no intravenous and no dye used. The person goes under the CT scanner, holds their breath for about one minute, the scan is taken and done. What do the results mean? For people between the ages of 40 and 75 without established heart artery disease, the score is used as follows. A score greater than 100 represents extensive plaque and an increased risk for future cardiac events (heart attack, blocked heart artery, stroke, cardiac death). In this case a statin (and perhaps aspirin 81 mg once per day) is recommended. A score between 1 and 99 is intermediate. Even a low calcium score (between 1 and 10) is associated with a two times greater risk for cardiac events compared to score of zero. In this population, a statin is recommended if high risk characteristics are present (age over 55, family history of premature heart disease, persistently elevated LDL cholesterol or triglycerides, evidence for inflammation or elevated lipoprotein a in the blood). 

 

What does a coronary calcium score of zero represent? There are two clinical possibilities. One is that there is no heart artery plaque. The other scenario is that there is soft or fatty plaque present, which has not yet calcified. Most studies have found that among patients with coronary calcium of zero, there is a very low likelihood of blockage in the heart arteries and a low risk for heart events (heart attack, stroke, death). However, one study looked at 10,000 people and found that 45% of them had a coronary score of zero. Among those with zero scores, 1.8% still had at least one artery blocked 50% or greater. The prognostic value of a zero score was less for those under the age of 45 (they likely had not had enough time for the plaque to calcify). In general, a coronary calcium score of zero is a good prognostic sign. How long does that prognostic value last? What is the warranty period of a calcium score of zero? A study showed that about 15% of people with initial calcium score of zero progressed to a score over 10 in about 5 to 8 years. In the study it was rare to progress to a calcium score over 100. Diabetic patients, active smokers and those with strong family history progressed more quickly. Based on these data, it is recommended that statin therapy be withheld for a patient with a calcium score of zero, unless they have diabetes, are smoking or there is a family history of premature heart disease. How often should the calcium score be repeated to reassess risk? For patients with a coronary calcium score of zero, repeating the study is recommended in 3 to 5 years. For patients with an elevated coronary calcium score who are already on statin, it is not recommended to have a follow up study. The reason is that the calcium score may go up on statin treatment. If the score goes up, we don’t know if there has been further plaque progression or increasing calcium in existing plaque- a sign of healing.

 

Using the coronary calcium can help predict the risk for future heart events in patients between 40 and 75 years old who have not yet had a cardiac issue (primary prevention). If you are like Bill and your coronary calcium score is greater than zero, initiating lifestyle changes and starting a statin can reduce the risk for a heart event in the future. If you are lucky like Hillary and your coronary calcium score is zero, the risk for future events is low. However, it is not a “get out jail free” card nor are you “saved by zero”. If coronary calcium score is zero and LDL cholesterol is high, then lifestyle changes should be incorporated even if starting a statin may be avoided. Vigilance is necessary with follow up lipid panels and repeat coronary calcium testing in 3 to 5 years. 

POTS or Why Am I Dizzy When I Stand Up?

 

When you think about, we shouldn’t be able to stand upright. Our ancient ancestors, floating around in the sea, used the water for everything; hydration, nutrition and support. The water buoyed them, there was no need for a spine or other elaborate bony structures. To leave the water and especially to walk upright on two legs, certain adaptations were needed. Skeletal features that evolved over time included a spine, hip bones, thigh bones and the muscles needed to keep the body upright and erect. Circulatory adaptations were needed as well. When we are upright, the heart has to pump blood against gravity to keep blood flowing to the brain. Blood pressure to the brain must be maintained otherwise when we stand up, the blood pressure would drop, the blood flow to the brain would decrease and we would pass out. How does the circulation respond to standing and why don’t we routinely pass out?

 

The mechanism that evolved to keep us upright is a blood pressure feedback loop that involves the heart, the brain and the blood vessels. On standing, blood pools in the veins in the legs. This causes a transient decrease in blood pressure. This drop in blood pressure is recognized by a sensor in the carotid artery (the carotid artery is the main artery supplying blood to the brain, the sensor is located in the carotid sinus, just outside of the skull). When the carotid sinus senses a lower blood pressure, it fires nerves which activate the sympathetic system. The sympathetic system constricts blood vessels, increases the heart rate and increases the amount of blood pumped by the heart ultimately restoring normal blood pressure to the brain and preventing passing out.

 

This mechanism is very effective at maintaining blood pressure. However, there are circumstances where the mechanism is overwhelmed causing dizziness or passing out. Instances include prolonged standing in a hot environment (think of a soldier standing for a long time in the hot sun), dehydration, or deconditioning from staying in bed for a long time. As we age, the mechanism isn’t as fast and we can have dizziness on rising quickly from a sitting or lying down position. If the mechanism isn’t working, it leads to passing out on standing, a condition called orthostatic hypotension (from the Greek ortho- straight and statikos- causing to stand; caused by standing erect; hypotension- low blood pressure). Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more within three minutes of standing. It is a significant medical problem whose incidence rises after age 65. It occurs in 6% of elderly people in the community and up to 50% of people in nursing homes. Orthostatic hypotension puts patients at risk for falls, as well as cardiac disease. Orthostatic hypotension occurs in patients with degenerative diseases of the autonomic nervous system (for example, Parkinson’s disease). It also occurs due to an impaired autonomic nervous system (for example, diabetes). Orthostatic hypotension can be diagnosed in the office or at the hospital bedside by checking blood pressure lying down and standing up. The formal way to diagnose it is with a tilt table test (strapping a patient to an upright table and checking blood pressure frequently). 

 

There are multiple ways to treat orthostatic hypotension. In milder forms, patients recognize that they are about to pass out and can sit or lay down to avoid falling. For more significant cases, the first step is to stop medications that can lower the blood pressure or exaggerate orthostatic symptoms. Medications to avoid include diuretics, most blood pressure meds, prostate medications (ex, Flomax or tamsulosin), antiparkinson agents and antidepressants. Other measures include increasing blood volume by keeping hydrated, ingesting salt tablets, or using a medication (fludrocortisone) which promotes salt retention. Pooling of blood in the veins of the lower legs can be decreased by using compression stockings. Lastly, medications that stimulate the sympathetic nervous system (such as midodrine or droxidopa, Northera) can be used. 

 

POTS (postural orthostatic tachycardia syndrome) is the most common form of orthostatic intolerance in young people. It usual affects young, pre-menopausal women with as many as 500,000 cases in the US. It is defined as an increase in the heart rate of 30 beats per minute or more within 10 minutes of standing, but without a decrease in blood pressure. The typical patient is a 30-year-old woman with a heart rate increment of 40 beats per min or more. Cardiovascular deconditioning is common. Therefore, the key to treatment is exercise. The exercise regimen should avoid the upright position (swimming or recumbent bike can be prescribed) until fitness improves. Liberal intake of fluids and salt, compression stockings and sleeping with the head of the bed greater than 30 degrees are other methods. Medications can be used in severe cases and include the same agents used for orthostatic hypotension. 

 

Whether you are young or old, if you have dizziness on rising there are measures you can take to avoid symptoms. If you have more severe symptoms or are passing out on standing, see your doctor to work through how to keep yourself upright.